Olivier Genée

Prognosis and 1-year mortality of intensive care unit patients with severe hepatic encephalopathy ☆

PURPOSE Data regarding outcome of patients with chronic liver disease with severe hepatic encephalopathy in intensive care unit are currently scarce. METHODS This study is a retrospective observational case series in a medical intensive care unit (ICU) in a university hospital from 1995 to 2005. Patients with hepatic encephalopathy (HE) (admitted with or developing) were identified. Clinical and laboratory parameters were analyzed to determinate predictors of ICU and 1-year mortality. RESULTS Seventy-one patients were included (53 male). Median Simplified Acute Physiology Score was 56 with Child-Pugh score 11 +/- 2. Seventy-six percent of patients were admitted with coma (Glasgow Coma Scale, 7.7 +/- 4). Eighty-two percent of patients required intubation, and 28% vasopressors. Thirty-five percent died during ICU stay. At 1 year, mortality was 54%. Univariate analysis identified arterial hypotension, mechanical ventilation, vasopressors at any time, acute renal failure, Simplified Acute Physiology Score, and sepsis associated with ICU mortality. In multivariate analysis, vasopressor use or acute renal failure was the main independent predictor of ICU death and 1-year mortality. Patients free of these risk factors, even requiring intubation, were identified as isolated HE, with lower mortality rates. CONCLUSION Predictors of outcome were similar to other groups of patients with liver disease admitted for other reasons. Intensive care unit mortality was lower than reported for other groups of patients with similar illness. Patients with severe HE admitted to ICU with no organ dysfunction other than mechanical ventilation had a better outcome and may require ICU admission.

Single high-dose erythropoietin administration immediately after reperfusion in patients with ST-segment elevation myocardial infarction: results of the erythropoietin in myocardial infarction trial.

BACKGROUND Preclinical studies and pilot clinical trials have shown that high-dose erythropoietin (EPO) reduces infarct size in acute myocardial infarction. We investigated whether a single high-dose of EPO administered immediately after reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) would limit infarct size. METHODS A total of 110 patients undergoing successful primary coronary intervention for a first STEMI was randomized to receive standard care either alone (n = 57) or combined with intravenous administration of 1,000 U/kg of epoetin β immediately after reperfusion (n = 53). The primary end point was infarct size assessed by gadolinium-enhanced cardiac magnetic resonance after 3 months. Secondary end points included left ventricular (LV) volume and function at 5-day and 3-month follow-up, incidence of microvascular obstruction (MVO), and safety. RESULTS Erythropoietin significantly decreased the incidence of MVO (43.4% vs 65.3% in the control group, P = .03) and reduced LV volume, mass, and function impairment at 5-day follow-up (all P < .05). After 3 months, median infarct size (interquartile range) was 17.5 g (7.6-26.1 g) in the EPO group and 16.0 g (9.4-28.2 g) in the control group (P = .64); LV mass, volume, and function were not significantly different between the 2 groups. The same number of major adverse cardiac events occurred in both groups. CONCLUSIONS Single high-dose EPO administered immediately after successful reperfusion in patients with STEMI did not reduce infarct size at 3-month follow-up. However, this regimen decreased the incidence of MVO and was associated with transient favorable effects on LV volume and function.

Electrical storm reversible by isoproterenol infusion in a striking case of early repolarization

A 40-year-old woman was referred to intensive care unit after recurrent ventricular fibrillation. She was free of cardiac medical history or medications. The resting ECG displayed an extended early repolarization in the inferior leads and all the precordial leads. Incessant ventricular fibrillations justified a treatment by intravenous amiodarone associated with general anaesthesia and mechanical ventilation without success on ventricular fibrillation. Because of a low heart rate intravenous isoproterenol infusion was initiated. Isoproterenol infusion was associated with heart rate acceleration and a decrease in J point elevation and the disappearance of ventricular fibrillation episodes. No cardiac disease was documented and the patient was implanted of a single chamber ICD. Six months later the patient was free of syncope and ventricular fibrillation on ICD memory. This case report demonstrates the usefulness and efficiency of the isoproterenol infusion to eliminate recurrent ventricular fibrillation in patients with early repolarization.

Cardiac Magnetic Resonance Imaging and Eosinophilic Endomyocardial Fibrosis

We report the case of a 41-year-old man who presented with lymphoma 2 years ago and was treated by chemotherapy. Biological findings revealed important eosinophilia, although explorations did not show any lymphoma recidivism or evidence of active infection. One month later, the patient presented with fever and clinical signs of heart failure as the onset of a central catheter infection occurred with methicillin-resistant Staphylococcus aureus bacteremia. Chest radiography revealed an enlarged cardiac shadow with a congestive vascular pattern (Figure, A). The ECG showed sinus tachycardia with incomplete left bundle-branch block (Figure, B). The echocardiogram revealed severe mitral and aortic regurgitation with apical filling of the left ventricle by a mobile structure (Figure, C). An initial diagnosis …

Fatal QT interval.

A 21-year-old woman, without medical history, was admitted after cardiac arrest. Cardiopulmonary resuscitation and use of semiautomatic defibrillator quickly restored sinus rhythm. Clinical examination was normal with no cardiac murmur or abnormal heart sound. Electrocardiogram revealed sinus rhythm with short QT interval. Serum electrolytes and arterial blood gazes were normal. One hour after admission, lethal ventricular fibrillation occurred. Factors that shorten QT interval including increase in heart rate, hyperthermia, increased calcium, or potassium plasma levels and acidosis were excluded. Short-QT syndrome has been recently recognized as a genetic ion channel dysfunction leading to an abbreviation of action potential and a potential substrate for arrhythmias. This syndrome is characterized by a short QT interval (typically <320 milliseconds), associated with a high incidence of sudden death, syncope, or atrial fibrillation in individuals with an apparently normal heart. Implementation of an internal cardiac defibrillator remains the only effective preventive treatment.

T2-mapping and T1-mapping detect myocardial involvement inTako-Tsubo cardiomyopathy: a preliminary experience

Background T2and T1-mapping are novel CMR techniques allowing objective tissue characterization. These techniques have been shown to be superior to dark blood imaging in NSTEMI patients in detecting ischaemic area at risk and acute oedema. These methods have not been assessed in Tako-Tsubo cardiomyopathy (TC).The aim of the study was to assess myocardial involvement using T2and T1mapping in Tako-Tsubo cardiomyopathy (TC).

Accuracy of a new method for semi-quantitative assessment of right ventricular ejection fraction by cardiovascular magnetic resonance: Right ventricular fractional diameter changes

OBJECTIVE Longitudinal shortening is traditionally considered the predominant part of global right ventricular (RV) systolic function. Less attention has been paid to transverse contraction. The aim of this study was to evaluate RV transverse motion by cardiovascular magnetic resonance (CMR) in a large cohort of patients and to assess its relationship with RV ejection fraction (RVEF). STUDY DESIGN We retrospectively analyzed the CMR scans of 300 patients referred to our center in 2010. RVEF was determined from short axis sequences using the volumetric method. Transverse parameters called RV fractional diameter changes were calculated after measuring RV diastolic and systolic diameters at basal and mid-level in short axis view (respectively FBDC and FMDC). We also measured the tricuspid annular plane systolic excursion (TAPSE) as a longitudinal reference. RESULTS Our population was divided into 2 groups according to RVEF. 250 patients had a preserved RVEF (>40%) and 50 had a RV dysfunction (RVEF ≤ 40%). Transverse and longitudinal motions were significantly reduced in the group with RV dysfunction (p<.0001). After ROC analysis, areas under the curve for FBDC, FMDC and TAPSE, were respectively 0.79, 0.82 and 0.72, with the highest specificity and sensitivity respectively of 88% and 68% for FMDC (threshold at 20%) for predicting RV dysfunction. FMDC had an excellent negative predictive value of 93%. CONCLUSION RV fractional diameter changes, especially at the mid-level, appear to be accurate for semi-quantitative assessment of RV function by CMR. A cut-off of 20% for FMDC differentiates patients with a low (EF≤40%) or a preserved RVEF.

Major ST-segment elevation hiding acute severe pancreatitis

A 78-year-old woman presented with abdominal pain in a suspicion of ethanol intoxication. Baseline 12-lead electrocardiogram showed a major ST-segment elevation suggestive of an acute myocardial infarction. Troponin I was 6.6 ng/mL. Transthoracic echocardiography found normal left ventricular ejection fraction, with no wall motion abnormality or pericardial effusion. Then, amylase and lipase serum levels were 1199 and 3873 IU, respectively, and primary coronary angiography was cancelled. At 48 hours, abdominal CT scan confirmed the diagnosis of severe acute pancreatitis. At 8 days, electrocardiogram showed inverted T waves without Q wave. Delayed cardiac magnetic resonance imaging showed no signs of myocarditis or ischemic sequelae, normal segmental wall motion, and preserved left ventricular ejection fraction (70%). Coronary angiography was also normal. Electrocardiographic (ECG) ST-segment elevation in a suspicion of acute thoracoabdominal pain may lead to rapid primary coronary angiography. We report a case of a pancreatitis mimicking an acute myocardial infarction, where transthoracic echocardiography was carried out, showing normal left ventricular function and thus postponing a potentially deleterious angiography. A 78-year-old woman with a history of chronic alcoholism, with no risk factor for coronary artery disease, was transferred to emergency department for abdominal pain. She had been found lying on the ground at her home in a suspicion of acute ethanol intoxication. At admission, she presented with global dehydration and anuria. Mean arterial blood pressure was 90 mm Hg, and heart rate was 100 beats per minute. Glasgow Coma Scale score was 15. Cardiopulmonary examination result was normal. A 12-lead ECG showed a sinus rhythm with narrow QRS complexes (short QRS duration was especially visible in lead V1) and a major ST-segment elevation in the infero-antero-lateral territory with a mirror image in leads aVR and aVL (Fig. 1A). Standard laboratory workup showed elevated myocardial necrosis markers (creatine phosphokinase [CPK], 7091 IU; troponin I, 6.6 ng/mL), normal serum 0735-6757/

Bi-ventricular failure following methadone overdose.

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T1 mapping, ECV and ICV before and after aortic valve replacement

Sir: We report the case of a 37year-old man admitted to intensive care unit for coma and hypotension following methadone reintroduction as opioid substitution. He was treated by methadone 60 mg daily, 3 years previously, and treatment was interrupted since opioid consumption recidivism. Incarcerated during 12 weeks, addiction was suspended and decision of methadone substitution was finally decided. Three hours after administration of 60 mg methadone, the patient presented with calm hyporeflexic coma with myosis, hypoventilation, bilateral pulmonary